Broker Application

General Information






Volume of business brokered to wholesalers
Products you wish to access*






Currently Contracted With Ryan Specialty Group

Contact Information

Name*
 Email*
  Professional Designations (If Any)
Agency Producers
Name
 Email
  Professional Designations (If Any)
 

Transportation Questionnaire

Business Volume
Which contracted insurance companies do you place these classes with*
Identify wholesalers and MGAs you place these classes with*
What companies do you access through these wholesalers/MGAs*
Why do you need us*
If we are able to meet your needs, approximately how much volume could be placed with our facility*

Additional Documents

THE FOLLOWING DOCUMENTS ARE REQUIRED IF APPROVED

1. A copy of your E & O Declarations page
2. A completed and signed W-9
3. A signed brokerage agreement (will be provided upon approval)

        

Interstate Insurance Management
2307 Menoher Blvd., Johnstown, PA 15905
Call: 814-255-7878
Fax: 814-255-6010
1-800-452-0297

Interstate Insurance Management is a series of RSG Underwriting Managers, LLC. RSG Underwriting Managers is a Delaware Series limited
liability company and a subsidiary of Ryan Specialty Group, LLC. In California: RSG Insurance Services, LLC License # 0E50879
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